The work of the centre is internationally recognised, having contributed significantly to advancing both medical practice and policy through its discoveries.

Its studies are regularly published in the most prestigious journals and it is a major training hub for respiratory medicine and immunology, attracting gifted PhD students and postdoctoral researchers from around the world to work and study in Newcastle.

Foster and Gibson's teams work under the umbrella of the Hunter Medical Research Institute, a partnership between the University of Newcastle and Hunter New England Health. They also collaborate with research groups in Sydney, Newcastle, Melbourne and Perth as part of the Cooperative Research Centre
for Asthma and Airways, a $55 million government-backed program.

Gibson is working at the clinical interface, using his role as a respiratory physician at the John Hunter Hospital in Newcastle to inform his research into treatments and management strategies for asthma and airway disease.

Foster, the University's Chair in Immunology, investigates the molecular and cellular mechanisms of disease in the laboratory. Both have a keen interest in unravelling the critical role of inflammation in asthma and other respiratory conditions.

"We are constantly on the lookout for better treatments but with a disease like asthma, management is also important," Gibson says.

"For some people, just understanding what is happening to them is enough to make a big difference to their condition and quality of life."

Gibson's clinically based team is involved in research projects with significant implications for future treatment and management of airway disease (see below).

Novel discoveries have also been made by the centre's laboratory-based researchers. These discoveries have enhanced the understanding of processes associated with the development and progression of respiratory diseases.

Centre scientists study the cellular and molecular functions of the diseases on animal models then collaborate with the clinical researchers to validate their findings using human tissue.

Foster says the centre is at the forefront of interpreting how inflammation, which underpins airway disease, occurs and of developing new anti-inflammatory treatments.

A major breakthrough was their research into how microRNA molecules, which regulate protein production in human cells, can cause inflammation in the body that can manifest as asthma. Working out how to control that inflammatory response has provided scientists with a therapeutic target, which could
lead to new treatments.

"Steroids are the conventional treatment, but they can have side effects and while they dampen response, they do not cure the disease," Foster explains.

"Also, not everyone is responsive to steroids and within that non-responsive group there is a lot of morbidity."

Foster says his team has made a significant contribution to the understanding of the mechanisms of steroid-resistant inflammatory pathways that may be relevant to asthma, bringing them closer to the goal of developing alternative treatments. Other critical areas of laboratory research focus on allergies,
viruses and infection as triggers for asthma.

While the two arms of research within the centre are undertaken by different teams, Foster says it is the critical mass that contributes to its overall success.

"What we have is diversity and common interest," he says. "There are similar centres of excellence around the world but they primarily do either clinical-based research or basic immunology. The way the two are integrated here is what makes us unique and underpins our success."

"People are willing to collaborate," Gibson agrees, "and it is only by linking patient-focused research with laboratory discoveries and evidence-based medicine that we are able to get these broad insights into disease."

Leading the way

Professor Peter Gibson's clinical research team is leading three groundbreaking projects that could revolutionise the treatment of asthma.

These specific projects involve better management of asthma in pregnancy, the development of a blood test to diagnose the disease and the treatment of non-eosinophilic asthma with macrolide antibiotics.

The team's study into asthma in pregnancy was prompted by the reluctance of women to use treatments during gestation, even though severe asthmatic episodes can be harmful to both mother and child.

As part of this project, researchers measured nitric oxide, which is produced by inflamed airways, in the pregnant patient's exhaled breath. They were then able to adjust the amount of medication according to the severity of the inflammation.

In many cases this reduced the amount of steroid that needed to be administered, which made women more likely to take their medication as they were less apprehensive about the treatment and its effects on their unborn child.

Another benefit was that the frequency of asthma exacerbations, or episodes, decreased because the condition was being better managed.

In another study, published this year in the American Journal of Respiratory and Critical Care Medicine, the team used the emerging scientific field of proteomics (the study of proteins) to identify four blood-based biomarkers that when analysed together can distinguish between asthma and chronic obstructive
pulmonary disease.

The two diseases share common symptoms, so are difficult to distinguish, but require different therapeutic approaches.

This finding could lead to the development of the first blood test for asthma, which would be a major diagnostic breakthrough.

The third project is the AMAZES study (Asthma and Macrolides: Azithromycin Efficacy and Safety). It will trial an alternative treatment, known as a macrolide antibiotic, for asthma that is not responsive to conventional steroid medication.

Steroids treat a particular cell, called an eosinophil, which is thought to provoke inflammation when present in increased levels. But research has established that up to half of adults with asthma symptoms have normal levels of eosinophils and respond poorly to conventional treatment.

The five-year, $2.9 million study is trialling the antibiotic on approximately 400 asthmatics in four cities and is the biggest study into non-eosinophilic asthma in the world. It is funded by the National Health and Medical Research Council.

Career Summary

Biography

Peter Gibson works as a doctor who cares for people with respiratory diseases and as a clinical scientist investigating the mechanisms and treatment of asthma, Chronic Obstructive Pulmonary Disease (COPD), cough, and other airway disorders.

He is a concept leader who has developed innovative approaches around inflammatory subtypes of asthma and cough; airway biomarkers; neurogenic mechanisms, laryngeal dysfunction and related treatments for refractory cough; multidimensional assessment and management of complex airway disorders such as severe asthma, airways diseases in the elderly, and asthma in pregnant women.

Peter's research metrics record a H index of 62 (Scopus 2015), 450 published articles, competitive research funding success, and effective mentorship of clinical researchers. His peers have awarded Peter several research medals and elected him as the president of the Thoracic Society of Australia and New Zealand (2015-6).

His research, clinical practice, and participation in guideline panels serve to bring research developments into focus as effective health care interventions that improve the health of people suffering from breathing disorders.

Research ExpertiseInflammation and immunological mechanism of airway diseases such as asthma, COPD, and cough. Clinical assessment and treatment of airway diseases. Practice guidelines and policy of respiratory diseases.

Pregnancy provides a unique challenge for maternal immunity, requiring the ability to tolerate the presence of a semi-allogeneic foetus, and yet still being capable of inducing an... [more]

Pregnancy provides a unique challenge for maternal immunity, requiring the ability to tolerate the presence of a semi-allogeneic foetus, and yet still being capable of inducing an immune response against invading pathogens. To achieve this, numerous changes must occur in the activity and function of maternal immune cells throughout the course of pregnancy. Respiratory viruses take advantage of these changes, altering the sensitive balance of maternal immunity, leaving the mother with increased susceptibility to viral infections and increased disease severity. Influenza virus is one of the most common respiratory virus infections during pregnancy, leading to an increased risk of ICU hospitalisations, pneumonia, acute respiratory distress syndrome and even death. Whilst much research has been performed to understand the changes that must take place in maternal immunity during pregnancy, considerable work is still needed to fully comprehend this tremendous feat. To date, few studies have focused on the alterations that occur in maternal immunity during respiratory virus infections. This review highlights the role of dendritic cells (DCs) and CD8 T cells during pregnancy, and the changes that occur in these antiviral cells following influenza virus infections.

Background: Asthma prevalence has increased in recent years, and evidence suggests that diet may be a contributing factor. Increased use of processed foods has led to a decrease i... [more]

Background: Asthma prevalence has increased in recent years, and evidence suggests that diet may be a contributing factor. Increased use of processed foods has led to a decrease in diet quality, which may be creating a pro-inflammatory environment, thereby leading to the development and/or progression of various chronic inflammatory diseases and conditions. Recently, the dietary inflammatory index (DII) has been developed and validated to assess the inflammatory potential of individual diets. Objective: This study aimed to examine the DII in subjects with asthma compared to healthy controls and to relate the DII to asthma risk, lung function and systemic inflammation. Methods: Subjects with asthma (n = 99) and healthy controls (n = 61) were recruited. Blood was collected and spirometry was performed. The DII was calculated from food frequency questionnaires administered to study subjects. Results: The mean DII score for the asthmatics was higher than the mean DII score for healthy controls (- 1.40 vs. - 1.86, P = 0.04), indicating that their diets were more pro-inflammatory. For every 1 unit increase in DII score, the odds of having asthma increased by 70% (OR: 1.70, 95% CI: 1.03, 2.14; P = 0.040). FEV1 was significantly associated with DII score (Ã = - 3.44, 95% CI: - 6.50, - 0.39; P = 0.020), indicating that for every 1 unit increase in DII score, FEV1 decreased by 3.44 times. Furthermore, plasma IL-6 concentrations were positively associated with DII score (Ã = 0.13, 95% CI: 0.05, 0.21; P = 0.002). Conclusion and Clinical Relevance: As assessed using the DII score, the usual diet consumed by asthmatics in this study was pro-inflammatory relative to the diet consumed by the healthy controls. The DII score was associated with increased systemic inflammation and lower lung function. Hence, consumption of pro-inflammatory foods may contribute to worse asthma status, and targeting an improvement in DII in asthmatics, as an indicator of suitable dietary intake, might be a useful strategy for improving clinical outcomes in the disease.

Objective Maternal asthma is the most common chronic disease complicating pregnancy and is a risk factor for bronchiolitis in infancy. Recurrent episodes of bronchiolitis are stro... [more]

Objective Maternal asthma is the most common chronic disease complicating pregnancy and is a risk factor for bronchiolitis in infancy. Recurrent episodes of bronchiolitis are strongly associated with the development of childhood asthma. Methods We conducted a follow-up study of infants born to women with asthma who completed a double-blind randomised controlled trial during pregnancy. In this trial, pregnant women with asthma were assigned to treatment adjustment by an algorithm using clinical symptoms (clinical group) or the fraction of exhaled nitric oxide (FeNO group) and we showed that the FeNO group had significantly lower asthma exacerbation rates in pregnancy. Results 146 infants attended the 12-month follow-up visit. Infants born to mothers from the FeNO group were significantly less likely to have recurrent episodes of bronchiolitis in the first year of life (OR 0.08, 95% CI 0.01 to 0.62; p=0.016) as compared with the clinical group. Conclusions Optimised management of asthma during pregnancy may reduce recurrent episodes of bronchiolitis in infancy, which could potentially modulate the risk to develop or the severity of emerging childhood asthma.

Background: Asthma is a heterogeneous inflammatory disease and eosinophilic, noneosinophilic and neutrophilic forms are recognised. While clinically similar to eosinophilic asthma... [more]

Background: Asthma is a heterogeneous inflammatory disease and eosinophilic, noneosinophilic and neutrophilic forms are recognised. While clinically similar to eosinophilic asthma, patients with non-eosinophilic asthma have different responses to treatment and little is known about the triggers of symptoms and inflammation. Objective: This study sought to characterise asthma control, exacerbation frequency and potential triggers of non-eosinophilic and specifically neutrophilic asthma such as infection, gastroesophageal reflux disease, and rhinosinusitis. Methods: Adults with asthma (n=65; doctor's diagnosis plus demonstrated response to bronchodilator and/or airways hyperresponsiveness to hypertonic saline) were recruited from the Respiratory and Sleep Medicine Ambulatory Care Service at John Hunter Hospital, NSW, Australia. Questionnaires were administered to assess gastroesophageal reflux disease, rhinosinusitis and asthma control. A sputum induction was performed and sputum was processed for assessment of inflammatory cells, infection, and lipid laden macrophages (Oil Red O). Results: Participants with neutrophilic asthma (n=11, 23%) had a higher frequency of primary care doctor visits for asthma exacerbations and a high prevalence (>70%) of chest infections in the previous 12 months. There was also an increased prevalence of rhinosinusitis (64%) and increased symptoms of gastroesophageal reflux disease compared to those with eosinophilic asthma. Conclusions: The clinical pattern of neutrophilic asthma is different from paucigranulocytic and eosinophilic asthma with evidence of abnormal upper airways responses. Specific and targeted treatment of these airway problems may assist in the control and management of neutrophilic asthma.

Patients with chronic obstructive pulmonary diseases (COPD) often experience comorbid conditions. The most common comorbidities that have been associated with COPD include cardiov... [more]

Patients with chronic obstructive pulmonary diseases (COPD) often experience comorbid conditions. The most common comorbidities that have been associated with COPD include cardiovascular diseases, lung cancer, metabolic disorder, osteoporosis, anxiety and depression, skeletal muscle dysfunction, cachexia, gastrointestinal diseases, and other respiratory conditions. Not only are comorbidities common but they also considerably influence disease prognosis and patients' health status, and are associated with poor clinical outcomes. However, perusal of literature indicates that little has been done so far to effectively assess, manage, and treat comorbidities in patients with COPD. The aim of this review is to comprehensively narrate the comorbid conditions that often coexist with COPD, along with their reported prevalence and their significant impacts in the disease management of COPD. A perspective on integrated disease management approaches for COPD is also discussed.

BACKGROUND: The addition of a long acting beta agonist (LABA) to inhaled corticosteroid (ICS) therapy can improve asthma symptoms and reduce exacerbations. The addition of LABA ma... [more]

BACKGROUND: The addition of a long acting beta agonist (LABA) to inhaled corticosteroid (ICS) therapy can improve asthma symptoms and reduce exacerbations. The addition of LABA may also have an ICS-sparing effect and permit a reduction in ICS maintenance dose. OBJECTIVES: To determine the efficacy of adding LABA to maintenance ICS therapy in reducing the requirement for ICS while maintaining control of chronic asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. Date of last search: November 2004 SELECTION CRITERIA: Parallel RCTs that compared reduced dose ICS in combination with LABA vs ICS alone in asthmatics requiring daily ICS. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation. Trials were analysed according to the following ICS dose comparisons: a fixed moderate/high dose or a reduced/tapering dose of the same ICS. MAIN RESULTS: 19 publications describing 10 trials of adults were included in the review. Studies that compared reduced dose (mean 60% reduction) ICS/LABA combination to a fixed moderate/high dose ICS found no significant difference in severe exacerbations requiring oral corticosteroids (RR 1.0, 95%CI 0.76 to 1.32), withdrawal due to worsening asthma (RR 0.82, 95%CI 0.5 to 1.35) or airway inflammation. There were also significant improvements in FEV1 (change from baseline WMD 0.10, 95%CI 0.07 to 0.12), morning & evening PEF and percent rescue free days with LABA. Two studies provided outcomes for a reduced/tapering ICS dose comparison. More participants receiving the LABA/reduced ICS combination achieved a reduction in ICS dose reaching significance in one study. A significant reduction of 253 mcg BDP was achieved in one study. AUTHORS' CONCLUSIONS: In adults with asthma, using moderate to high maintenance doses of ICS, the addition of LABA has an ICS-sparing effect. The addition ofLABA permits more participants on minimum maintenance ICS to reduce ICS. The precise magnitude of the ICS dose reduction requires further study.

BACKGROUND: Asthma education and self-management are key recommendations of asthma management guidelines because they improve health outcomes. There are several different modaliti... [more]

BACKGROUND: Asthma education and self-management are key recommendations of asthma management guidelines because they improve health outcomes. There are several different modalities for the delivery of asthma self-management education. OBJECTIVES: We evaluated programmes that: 1) Optimised asthma control through inhaled corticosteroid use by regular medical review or optimised asthma control by individualised written action plans 2) Used written self-management plans based on peak expiratory flow self-monitoring compared with symptom self-monitoring 3) Compared different options for the delivery of optimal self-management programmes. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised trials of asthma self-management education interventions in adults over 16 years of age with asthma. DATA COLLECTION AND ANALYSIS: Fifteen trials met the inclusion criteria. Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation. MAIN RESULTS: 1) Six studies compared optimal self-management allowing self-adjustment of medications according to an individualised written action plan to adjustment of medications by a doctor. These two styles of asthma management gave equivalent effects for hospitalisation, ER visits, unscheduled doctor visits and nocturnal asthma. 2) Self-management using a written action plan based on PEF was found to be equivalent to self-management using a symptoms based written action plan in the six studies which compared these interventions. 3) Three studies compared self-management options. In one, that provided optimal therapy but tested the omission of regular review, the latter was associated with more health centre visits and sickness days. In another, comparing high and low intensity education, the latter was associated with more unscheduled doctor visits. In a third, no difference in health care utilisation or lung function was reported between verbal instruction and written action plans. REVIEWER'S CONCLUSIONS: Optimal self-management allowing for optimisation of asthma control by adjustment of medications may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualised written action plans based on peak expiratory flow are equivalent to action plans based on symptoms. Reducing the intensity of self-management education or level of clinical review may reduce its effectiveness.

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been co... [more]

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education. OBJECTIVES: The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and two reviewers extracted data independently. Study authors were contacted for missing information. MAIN RESULTS: Twelve trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no significant effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but in two studies, perceived asthma symptoms did improve after limited asthma education (odds ratio 0.44, 95% confidence interval 0.26 to 0.74). In one study, limited asthma education was associated with reduced emergency department visits (reduction of -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18). REVIEWER'S CONCLUSIONS: Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma although perceived symptoms may improve. Provision of information in the emergency department may be effective, but this needs to be confirmed.

The expiratory airflow obstruction that characterises chronic obstructive pulmonary disease is usually progressive over time and caused by emphysema, obliterative bronchiolitis, a... [more]

The expiratory airflow obstruction that characterises chronic obstructive pulmonary disease is usually progressive over time and caused by emphysema, obliterative bronchiolitis, and mucus hypersecretion. Stopping smoking is the only measure that slows the progression of chronic obstructive pulmonary disease, and smokers should be encouraged to stop at all stages of the disease. The effects of medication are limited, and need to be balanced against cost and adverse effects. Bronchodilators, given by puffer and spacer rather than by nebuliser, are effective. Avoid inhaled corticosteroids unless there is associated asthma. Pulmonary rehabilitation leads to important improvements in quality of life. Influenza vaccination is helpful. Comorbidity from cardiac disease and sleep disordered breathing are common and can be effectively treated. New therapies under evaluation include lung volume reduction surgery, non-invasive ventilation, and anti-inflammatory drugs.

2001

Gibson PG, 'Outcomes of the Cochrane Airways Group International Conference', Australian Prescriber, 24 78-79 (2001) [C3]

Arnold DJ, Gibson PG, 'Prevalence of long term oral corticosteroid use and treatment for osteoporosis in chronic obstructive pulmonary disease (copd) or asthma', Respirology, 6 (2001)

Aim: To determine the prevalence of long term (>6 months) oral corticosteroid use and osteoporosis therapy (treatment or prevention) in patients hospitalised with COPD or asthma. ... [more]

Aim: To determine the prevalence of long term (>6 months) oral corticosteroid use and osteoporosis therapy (treatment or prevention) in patients hospitalised with COPD or asthma. Method: All patients admitted to hospital under the care of the respiratory service with a history of COPD or asthma were interviewed to assess their use of OCS, history of osteoporosis and therapy for osteoporosis. Results: 67 patients (meanÂ±SD age 63Â±17) were enrolled, 48 with COPD and 19 with asthma. 19(28%) were on long term OCS and of these 7(10%) had a previous diagnosis of osteoporosis (5 had had a fracture and all were on osteoporosis therapy; 2 had had no fracture and 1 was on therapy). Of the 12( 18%) patients on long term OCS with no diagnosis of osteoporosis none were on preventative therapy. Of 48 patients not on long term OCS 8 had a previous diagnosis of osteoporosis but only 3 were on therapy. Overall 27 (40%) of 67 patients were on long term OCS or had a previous diagnosis of osteoporosis, 13 (19%) had had a fracture and 11 ( 16%) were on osteoporosis treatment. Conclusion: Amongst patients admitted to hospital with COPD or asthma use of long term OCS or history of osteoporosis is common, while therapy for prevention or treatment of osteoporosis is uncommon.

BACKGROUND: Allergic Broncho-pulmonary Aspergillosis is hypersensitivity to the fungus Aspergillus fumigatus that complicates patients with asthma and cystic fibrosis. The mainsta... [more]

BACKGROUND: Allergic Broncho-pulmonary Aspergillosis is hypersensitivity to the fungus Aspergillus fumigatus that complicates patients with asthma and cystic fibrosis. The mainstay of treatment for ABPA remains oral corticosteroids, though this does not completely prevent exacerbations and may not prevent the decline in lung function. OBJECTIVES: The purpose of this review was to determine the efficacy of azoles in the treatment of Allergic Broncho-pulmonary Aspergillosis. SEARCH STRATEGY: The Cochrane Airways Group Asthma register was searched using the terms: (allergic bronchopulmonary aspergillosis OR aspergillosis OR allergic pulmonary aspergillosis OR allergic fungal and disease OR allergic mycotic and disease) AND (azole OR triazole OR itraconazole OR ketoconazole). SELECTION CRITERIA: All controlled trials that assessed the effect of azole antifungal agents compared to placebo or other standard therapy for ABPA were reviewed. Patients with cystic fibrosis were not included. DATA COLLECTION AND ANALYSIS: All identified trials were independently reviewed by both reviewers & all data collected. Trial quality was scored by the Cochrane assessment of allocation concealment & the Jadad scale of methodological quality. MAIN RESULTS: Twelve trials were identified, but only three were prospective, randomised and controlled. One demonstrated a reduction in immunological markers of disease activity and symptom scores using ketoconazole 400 mg daily for 12 month. There was no significant improvement in lung function. The other two examined the use of itraconazole for 16 weeks. In one there was a reduction in sputum eosinophils by 35% compared to 19% with placebo (p<0.01). In the same trial, the number of exacerbations requiring oral corticosteroids was 0.4 per patient with itraconazole compared with 1.3 per patient with placebo (p<0.03). Meta analysis of data from both trials showed that itraconazole treated patients were more likely to have decline in serum IgE over 25% or more (Odds Ratio 3.3; 95% confidence intervals 1.3, 8.2). REVIEWER'S CONCLUSIONS: Itraconazole modifies the immunologic activation associated with ABPA and improves clinical outcome in ABPA at least over the period of 16 weeks.

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been co... [more]

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the strength of evidence supporting Step 6 of the Australian Asthma Management Plan: "Educate and Review Regularly"; to test whether health outcomes are influenced by education and self-management programmes. OBJECTIVES: The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised trials of self-management education in adults over 16 years of age with asthma. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation. MAIN RESULTS: Twenty-five trials were included. Self-management education was compared with usual care in 22 studies. Self-management education reduced hospitalisations (odds ratio 0.57, 95% confidence interval 0.38 to 0.88); emergency room visits (odds ratio 0.71, 95% confidence interval (0.57 to 0.90); unscheduled visits to the doctor (odds ratio 0.57, 95% confidence interval 0.40 to 0.82); days off work or school (odds ratio 0.55, 95% confidence interval 0.38 to 0. 79); and nocturnal asthma (odds ratio 0.53, 95% confidence interval 0.39 to 0.72). Measures of lung function were little changed. Self-management programmes that involved a written action plan showed a greater reduction in hospitalisation than those that did not (odds ratio 0.35, 95% confidence interval 0.18 to 0.68). People who managed their asthma by self-adjustment of their medications using an individualised written plan had better lung function than those whose medications were adjusted by a doctor. REVIEWER'S CONCLUSIONS: Training in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appears to improve health outcomes for adults with asthma. Training programmes which enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.

BACKGROUND: Asthma and gastro-oesophageal reflux are both common medical conditions and often co-exist. Studies have shown conflicting results concerning the effects of lower oeso... [more]

BACKGROUND: Asthma and gastro-oesophageal reflux are both common medical conditions and often co-exist. Studies have shown conflicting results concerning the effects of lower oesophageal acidification as a trigger of asthma. Furthermore, asthma might precipitate gastro-oesophageal reflux. Thus a temporal association between the two does not establish that gastro-oesophageal reflux triggers asthma. Randomised trials of a number of treatments for gastro-oesophageal reflux in asthma have been conducted, with conflicting results. OBJECTIVES: The objective of this review was to evaluate the effectiveness of treatments for gastro-oesophageal reflux in terms of their benefit on asthma. SEARCH STRATEGY: The Cochrane Airways Group trials register, review articles and reference lists of articles were searched. SELECTION CRITERIA: Randomised controlled trials of treatment for oesophageal reflux in adults and children with a diagnosis of both asthma and gastro-oesophageal reflux. DATA COLLECTION AND ANALYSIS: Trial quality and data extraction were carried out by two independent reviewers. Authors were contacted for confirmation or more data. MAIN RESULTS: Nine trials met the inclusion criteria. Interventions included proton pump inhibitors (n=3), histamine antagonists (n=5), surgery (n=1) and conservative management (n=1). Treatment duration ranged from 1 week to 6 months. A temporal association between asthma and gastro-oesophageal reflux was investigated in 4 trials and found to be present in a proportion of participants in these trials. Anti-reflux treatment did not consistently improve lung function, asthma symptoms, nocturnal asthma or the use of asthma medications. REVIEWER'S CONCLUSIONS: In asthmatic subjects with gastro-oesophageal reflux, (but who were not recruited specifically on the basis of reflux-associated respiratory symptoms), there was no overall improvement in asthma following treatment for gastro-oesophageal reflux. Subgroups of patients may gain benefit, but it appears difficult to predict responders.

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been co... [more]

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education. OBJECTIVES: The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information. MAIN RESULTS: Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18). REVIEWER'S CONCLUSIONS: Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been co... [more]

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education. OBJECTIVES: The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information. MAIN RESULTS: Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18). REVIEWER'S CONCLUSIONS: Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been co... [more]

BACKGROUND: A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the strength of evidence supporting Step 6 of the Australian Asthma Management Plan: "Educate and Review Regularly"; to test whether health outcomes are influenced by education and self-management programmes. OBJECTIVES: The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. SELECTION CRITERIA: Randomised trials of self-management education in adults over 16 years of age with asthma. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation. MAIN RESULTS: Twenty-five trials were included. Self-management education was compared with usual care in 22 studies. Self-management education reduced hospitalisations (odds ratio 0.57, 95% confidence interval 0.38 to 0.88); emergency room visits (odds ratio 0.71, 95% confidence interval (0.57 to 0.90); unscheduled visits to the doctor (odds ratio 0.57, 95% confidence interval 0.40 to 0.82); days off work or school (odds ratio 0.55, 95% confidence interval 0.38 to 0. 79); and nocturnal asthma (odds ratio 0.53, 95% confidence interval 0.39 to 0.72). Measures of lung function were little changed. Self-management programmes that involved a written action plan showed a greater reduction in hospitalisation than those that did not (odds ratio 0.35, 95% confidence interval 0.18 to 0.68). People who managed their asthma by self-adjustment of their medications using an individualised written plan had better lung function than those whose medications were adjusted by a doctor. REVIEWER'S CONCLUSIONS: Training in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appears to improve health outcomes for adults with asthma. Training programmes which enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.

BACKGROUND: Asthma and gastro-oesophageal reflux are both common medical conditions and often co-exist. Studies have shown conflicting results concerning the effects of lower oeso... [more]

BACKGROUND: Asthma and gastro-oesophageal reflux are both common medical conditions and often co-exist. Studies have shown conflicting results concerning the effects of lower oesophageal acidification as a trigger of asthma. Furthermore, asthma might precipitate gastro-oesophageal reflux. Thus a temporal association between the two does not establish that gastro-oesophageal reflux triggers asthma. Randomised trials of a number of treatments for gastro-oesophageal reflux in asthma have been conducted, with conflicting results. OBJECTIVES: The objective of this review was to evaluate the effectiveness of treatments for gastro-oesophageal reflux in terms of their benefit on asthma. SEARCH STRATEGY: The Cochrane Airways Group trials register, review articles and reference lists of articles were searched. SELECTION CRITERIA: Randomised controlled trials of treatment for oesophageal reflux in adults and children with a diagnosis of both asthma and gastro-oesophageal reflux. DATA COLLECTION AND ANALYSIS: Trial quality and data extraction were carried out by two independent reviewers. Authors were contacted for confirmation or more data. MAIN RESULTS: Nine trials met the inclusion criteria. Interventions included proton pump inhibitors (n=3), histamine antagonists (n=5), surgery (n=1) and conservative management (n=1). Treatment duration ranged from 1 week to 6 months. A temporal association between asthma and gastro-oesophageal reflux was investigated in 4 trials and found to be present in a proportion of participants in these trials. Anti-reflux treatment did not consistently improve lung function, asthma symptoms, nocturnal asthma or the use of asthma medications. REVIEWER'S CONCLUSIONS: In asthmatic subjects with gastro-oesophageal reflux, (but who were not recruited specifically on the basis of reflux-associated respiratory symptoms), there was no overall improvement in asthma following treatment for gastro-oesophageal reflux. Subgroups of patients may gain benefit, but it appears difficult to predict responders.

BACKGROUND: Theophylline and long acting beta2-agonists are bronchodilators used for the management of persistent asthma symptoms, especially nocturnal asthma. They represent diff... [more]

BACKGROUND: Theophylline and long acting beta2-agonists are bronchodilators used for the management of persistent asthma symptoms, especially nocturnal asthma. They represent different classes of drug with differing side-effect profiles. OBJECTIVES: To assess the comparative efficacy, safety and side-effects of long-acting beta-agonists and theophylline in the maintenance treatment of asthma. SEARCH STRATEGY: Randomised, controlled trials (RCTs) were identified using the Cochrane Airways Group register. The register was searched using the following terms: asthma and theophylline and long acting beta-agonist or formoterol or foradile or eformoterol or salmeterol or bambuterol or bitolterol. Titles and abstracts were then screened to identify potentially relevant studies. The bibliography of each RCT was searched for additional RCTs. Authors of identified RCTs were contacted for other relevant published and unpublished studies. SELECTION CRITERIA: All included studies were RCTs involving adults and children with clinical evidence of asthma. These studies must have compared oral sustained release and/or dose adjusted theophylline with an inhaled long-acting beta-agonist. DATA COLLECTION AND ANALYSIS: Potentially relevant trials, identified by screening titles and/or abstracts, were obtained. Two reviewers independently assessed full text versions of these trials to decided whether the trial should be included in the review, and assessed its methodological quality. Where there was disagreement between reviewers, this was resolved by consensus, or reference to a third party. Data were extracted by two independent reviewers. Inter-rater reliability was assessed by simple agreement. Study authors were contacted to clarify randomisation methods, provide missing data, verify the data extracted and identify unpublished studies. Relevant pharmaceutical manufacturers were also contacted. MAIN RESULTS: Six trials met the inclusion criteria. Five used salmeterol and one, biltoterol. They were of varying quality. There was a trend for salmeterol to improve FEV1 more than theophylline in three studies and salmeterol use was associated with more symptom free nights. Bitolterol, used in only one study, was reported to be less effective than theophylline. Subjects taking salmeterol experienced fewer adverse events than those using theophylline (Relative Risk 0.38; 95%Confidence Intervals 0.25, 0.57). Significant reductions were reported for central nervous system adverse events (Relative Risk 0.51; 95%Confidence Intervals 0.30, 0.88) and gastrointestinal adverse events (Relative Risk 0.32; 95%Confidence Intervals 0.17, 0.59). REVIEWER'S CONCLUSIONS: Salmeterol may be more effective than theophylline in reducing asthma symptoms including night waking and improving lung function. More adverse events occurred in subjects using theophylline when compared to salmeterol.

BACKGROUND: Allergic Broncho-pulmonary Aspergillosis (ABPA) is hypersensitivity to the fungus Aspergillus Fumigatus that complicates patients with asthma and cystic fibrosis. The ... [more]

BACKGROUND: Allergic Broncho-pulmonary Aspergillosis (ABPA) is hypersensitivity to the fungus Aspergillus Fumigatus that complicates patients with asthma and cystic fibrosis. The condition usually results in an increase in symptoms, a greater reliance on corticosteroids to control the disease process and may lead to a progressive decline in lung function. The mainstay of treatment for ABPA remains oral corticosteroids, though this does not completely prevent exacerbations and may not prevent the decline in lung function. OBJECTIVES: The purpose of this review is to determine the efficacy of azoles in the treatment of ABPA SEARCH STRATEGY: An initial search was carried out using the Cochrane Airways Group Asthma RCT register. The register was searched using the following terms: (asthma or wheeze) and (allergic bronchopulmonary aspergillosis or aspergillosis or allergic pulmonary aspergillosis or allergic fungal and disease or allergic mycotic and disease) and (azole or triazole or itraconazole or ketoconazole). SELECTION CRITERIA: All controlled trials that assessed the effect of azole antifungal agents compared to placebo or other standard, for any duration or dose regimen in subjects with ABPA of any age or severity were reviewed. Studies in languages other than English were included. DATA COLLECTION AND ANALYSIS: All identified trials were independently reviewed by both reviewers & all data collected. Trial quality was scored by the Cochrane assessment of allocation concealment & the Jadad scale of methodological quality. MAIN RESULTS: A total of 11 trials were identified concerning the use of azoles in ABPA. Only two prospective controlled trials were identified. The first trial examined the use of Ketoconazole 400 mg daily for 12 months and demonstrated a reduction in immunological markers of disease activity and symptom scores, there was no significant improvement in lung function. The other trial examined the use of itraconazole for 16 weeks. This demonstrated a reduction in corticosteroid usage, an improvement in immunological markers, an improvement in pulmonary function and exercise tolerance. This study was only available as an abstract and limited details were available. REVIEWER'S CONCLUSIONS: There is insufficient information available to recommend the use of azole anti-fungal agents in the routine treatment of patients with ABPA.

In mild asthma there is typically an infiltrate with eosinophils, which improves with corticosteroid therapy. Asthma can persist despite high dose inhaled corticosteroid therapy (... [more]

In mild asthma there is typically an infiltrate with eosinophils, which improves with corticosteroid therapy. Asthma can persist despite high dose inhaled corticosteroid therapy (ICS). Aim: The aim of this study was to establish the characteristics of airway inflammation in asthma, which persists despite high dose inhaled corticosteroids. Method: Adults (n=73) with asthma and persistent symptoms who were taking =1000g ICS underwent hypertonic saline challenge and sputum induction. Sputum was dispersed using dithiothreitol and assayed for total cell count, cellular differential, supernatant eosinophil cationic protein (ECP ng/mL), myeloperoxidase (MPO ng/mL) and interleukin-8 (IL-8 ng/mL). Subjects were categorised into 4 groups based upon the presence or absence of airway hyperresponsiveness (AHR) and increased sputum eosinophils (E; being >5%). Results: Subjects with eosinophilic AHR (EAR n=16) had 22% E, compared to those with noneosinophilic AHR (NEAR, n=40) who had 1.5% E. Those with asthma in remission (normal AHR and E; n=14) had 1.2% E. Neutrophil % was similar in all 3 groups (p>0.05). ECP was highest in the EAR positive group (7572) compared with NEAR (2834) and remission (504; p = 0.001). MPO was elevated in NEAR (275) and EAR (253) compared with remission (189; p = 0.05). IL-8 levels were highest in NEAR (86.2) compared to EAR (36.5) and remission (12.9; p = 0.03). Conclusion: Asthma which remains symptomatic despite high dose ICS consists of 2 different inflammatory patterns. While some have typical eosinophil inflammation, the most common pattern is cellular (neutrophil and eosinophil) activation, with suppressed eosinophil counts. This may be mediated by IL-8 secretion. There is heterogeneity of airway inflammation in symptomatic asthma.

Induced sputum examination has emerged as an important investigative tool in airway diseases. Sputum can be easily induced by ultrasonic nebulization of Hypertonic saline. Inprove... [more]

Induced sputum examination has emerged as an important investigative tool in airway diseases. Sputum can be easily induced by ultrasonic nebulization of Hypertonic saline. Inprovements in sputum processing have established that sputum provides reproducible measurements of cell counts and fluid phase mediators. Adults and children with stable asthma demonstrate an infiltrate of eosinophils. With an exacerbation of asthma the eosinophil infiltrate increases and the cells become activated in response to cytokines including interleukin-5. A neutrophil infiltrate may accompany some exacerbations. Exacerbations resolve under the influence of corticosteroid therapy. Eosinophils undergo apoptosis and are removed by macrophages. Eosinophilic bronchitis is an important component in up to 20% of patients with chronic cough. Sputum examination promises to be an important technique to facilitate the understanding and management of asthma and cough in adults and children.

The objective of this study is to examine the treatment of exacerbations of chronic obstructive airways disease (COAD) in the hospital and in the community setting using a retrosp... [more]

The objective of this study is to examine the treatment of exacerbations of chronic obstructive airways disease (COAD) in the hospital and in the community setting using a retrospective study of patients admitted to a major teaching hospital combined with a general practice chart audit. The admission records for 248 admissions from 128 patients were reviewed. Most patients (70%) had visited their GP within 2 weeks of admission, antibiotics were prescribed for 30% of the exacerbations while 51% were treated with ingested corticosteroids. During hospitalization, features of infection were present in 64% (n = 159) of exacerbations and 79% (n = 196) received antibiotics. Patients were also treated with nebulized bronchodilators, oxygen and corticosteroids (82%). The median length of stay was 10 days (range 0-55). There was a high readmission rate (70%) at 1 year for exacerbation of COAD during the study period. Exacerbations of COAD frequently demonstrated the clinical features of infection. Treatment in general practice was less intensive than in hospital, and there is a need to reconcile these differences with studies of early therapy with antibiotics and corticosteroids. Although corticosteroids were used less often in general practice, the literature in this area is not conclusive and the evidence supporting guideline recommendations is not explicit. There are opportunities to examine the role of early therapy and early discharge programmes to minimize the cost burden from exacerbations of COAD.

Objective Tb calculate the costs of tobacco-related paediatric illness attributable to parental smoking in the United States. Design Cost-estimate study using techniques of litera... [more]

Objective Tb calculate the costs of tobacco-related paediatric illness attributable to parental smoking in the United States. Design Cost-estimate study using techniques of literature synthesis to generate the incidence and costs of tobacco-related paediatric illness. Data sources and selection English-language articles were identified by searching MEDLINE, HEALTH, BIOETHICSLINE, ECONLIT, and Social Sciences Citation Index from January 1980 to May 1996. Articles that included children in the age range of neonate to 18 years were used. For cost data, only articles referring to the United States were included. National databases and textbooks were used to obtain estimates of the prevalence of parental smoking and the incidence of the diseases in question. Main outcome and cost measures Best estimates of the relative risk for smoking-related diseases in children exposed to parental smoking were obtained, and the attributable risk fraction (the fraction of cases of disease that would not have occurred if no one in the population had been exposed) and direct medical expenditures were calculated. The cost of illness (based on costs for loss of life) was also calculated. Costs were adjusted to 1993 U.S. dollars. Main results Estimated annual excess cases of childhood illness and death caused by parental smoking in the United States were 5 400 000 and 6200, respectively, leading to direct medical costs of $4.6 billion and loss-of-life costs of $8.2 billion (Table). Conclusion Loss-of-life cost for paediatric illness associated with parental smoking was estimated at U.S. $8.2 billion per year.

Corticosteroids are essential to reverse the eosinophilic airway inflammation which causes symptomatic exacerbations of asthma. Much of the current variation in clinical practice ... [more]

Corticosteroids are essential to reverse the eosinophilic airway inflammation which causes symptomatic exacerbations of asthma. Much of the current variation in clinical practice is not justified by data from clinical trials. Oral prednisolone is as effective as intravenous therapy and very high doses of corticosteroid are no better than modest doses (30- 50 mg prednisolone). Corticosteroids should be given twice a day for optimum effect. Therapy does not need to be tapered, but can be ceased abruptly after 10 days in most patients who are also taking high-dose inhaled corticosteroids. There is an increasing role for inhaled corticosteroids in the management of mild exacerbations of asthma. The dose, route and duration of therapy need to be defined for each patient and written down as part of an action plan to enable early intervention in future exacerbations.

National asthma management guidelines have improved awareness of the rising morbidity and mortality from asthma but have not been widely implemented at a local level. This paper d... [more]

National asthma management guidelines have improved awareness of the rising morbidity and mortality from asthma but have not been widely implemented at a local level. This paper describes the use of continuous quality improvement techniques to facilitate the implementation of asthma management guidelines within a tertiary hospital setting. A baseline audit demonstrated satisfactory emergency assessment and treatment, but identified poor compliance with the patient education aspects of the asthma management plan. An evaluation of the literature demonstrated that programs combining asthma education and management were effective when directed towards adults with a recent severe asthma exacerbation. An asthma education and management service was developed to address these deficits. A repeat audit was conducted which identified improvements in asthma control and management skills for patients attending the education program, together with reductions in asthma re-admission rates for patients referred to the service. Ongoing quality assessments will target nonattenders to the service and the maintenance of asthma skills. An area Asthma Health Outcomes Council was formed to address the issues of asthma management throughout the area health service.

The quality of medical education during internship is a cause for concern. This paper describes a structured educational programme for interns that was based around learning modul... [more]

The quality of medical education during internship is a cause for concern. This paper describes a structured educational programme for interns that was based around learning modules, clinical attachments and bedside teaching. The programme was incorporated into the term rotation of interns within an Area Health Service, and evaluated. Learning modules were timetabled by a Programme Coordinator and interns were reminded to attend. Clinical attachments were organized by the interns from a list of willing supervisors. Attendance at timetabled learning modules averaged 67%, which was greater than the 27% attendance at clinical attachments. Both sessions received high ratings for quality and clinical relevance. This structured education programme was based upon adult learning methods and was both feasible and well received by interns. Intern training programmes need to be programmed into the working week to ensure attendance, and modified following evaluation by interns. Such programmes should be considered by all hospitals to which interns are allocated.

The relevance of increased methacholine airway responsiveness detected in children with no current or past symptoms of asthma is not known. We wished for determine whether the pre... [more]

The relevance of increased methacholine airway responsiveness detected in children with no current or past symptoms of asthma is not known. We wished for determine whether the presence of airway hyperresponsiveness in asymptomatic children is also associated with abnormal variability of peak expiratory flow (PEF). In 12 asymptomatic children with methacholine hyperresponsiveness, we examined the diurnal variation of peak expiratory flow (PEF) and response to inhaled bronchodilator. Twelve asthmatic children with a comparable range of methacholine hyperresponsiveness, and 12 normal children without methacholine responsiveness, were used as positive and negative controls. The children were aged 11 (range 9-14) yrs. The mean diurnal variation of PEF in those children with asymptomatic hyperresponsiveness was increased at 9.3%, to a degree comparable to the symptomatic asthmatic children (10.7%), and greater than the normal children (5.7%). Methacholine stimulated airway constriction was associated with symptoms in subjects from each group, indicating that the children were capable of perceiving airway constriction. We conclude that asymptomatic children with methacholine airway hyperresponsiveness have other evidence of mild variable airflow obstruction with increased diurnal PEF variability, and can perceive airflow limitation. The lack of symptoms in the children with airway hyperresponsiveness could be due to an insufficient stimulus to cause symptomatic obstruction, or the absence of eosinophilic airway inflammation, which may be a requirement for the development of symptomatic airway hyperresponsiveness.

The purpose of this study was to examine airway responsiveness, sputum cells and the effects of inhaled corticosteroid in the chronic cough syndrome associated with eosinophilic b... [more]

The purpose of this study was to examine airway responsiveness, sputum cells and the effects of inhaled corticosteroid in the chronic cough syndrome associated with eosinophilic bronchitis. We studied nine consecutive referrals with chronic cough, sputum with >10% eosinophils, normal spirometry, and normal methacholine airway responsiveness. Clinical assessment, sputum analysis, allergy skin tests and a methacholine inhalation test were performed at the first visit. Peak expiratory flow (PEF) was measured twice daily for 1 week followed by an adenosine monophosphate (AMP) inhalation test. Subjects were then treated with inhaled beclomethasone 0.4 mg twice daily for 7 days. Sputum analysis and measurement of methacholine responsiveness were then repeated. Excessive airway narrowing to methacholine was not present in any of the subjects. A methacholine plateau response was present in five subjects. Hyperresponsiveness to AMP was absent in six of the nine subjects, and PEF variability was not increased for eight subjects. Corticosteroid therapy led to a reduction in sputum eosinophil counts from 40.1 (SD 21 4)% to 4.0 (4.5)% but there was no significant change in metachromatic cell counts (0.8 SD 0.5% vs 0.6 SD 0.6%) or total cell counts. Methacholine responsiveness improved within the normal range in the three subjects in whom it could be determined. Chronic cough associated with eosinophilic airway inflammation can occur in the absence of variable airflow obstruction (asthma) and can improve after treatment with inhaled corticosteroid. This treatment can reduce the level of methacholine responsiveness within the normal range and reduces sputum eosinophils but not mast eels. These results suggest that the occurrence of variable airflow obstruction depends on the baseline level of methacholine responsiveness, the degree of eosinophilic infiltration and the degree to which methacholine responsiveness becomes heightened.

Mast cell mediators are known to contribute to the pathogenesis of asthma. There is some disagreement concerning the numbers of mast cells in asthmatic mucosa. In this study a sta... [more]

Mast cell mediators are known to contribute to the pathogenesis of asthma. There is some disagreement concerning the numbers of mast cells in asthmatic mucosa. In this study a standardized bronchial brush technique was developed and used to assess intraepithelial mast cells and other inflammatory cells in allergic and nonallergic asthmatic and nonasthmatic subjects. A total of 10 nonasthmatic (5 allergic) and 13 asthmatic (8 allergic) subjects with stable controlled asthma treated with Ã-agonist only were assessed by history, spirometry, allergy prick tests, and methacholine airway responsiveness. During fiberoptic bronchoscopy, bronchoalveolar lavage (BAL) was performed from the middle lobe and standardized bronchial brushings were taken from the lingula and left lower lobe bronchi. Quantitative cell counts were performed blind to the clinical characteristics of the subjects. The average total cell recovery from the brushings was 1.04 (SEM 0.09) x 106 ml, with a cell viability of 64% (5.3%). Reproducible total cell and mast cell counts were obtained from brushings taken from two lobar bronchi (ICC 0.86). Mast cells were significantly elevated in asthmatic compared with nonasthmatic subjects (1.5 Â± 0.34 versus 0.15 Â± 0.06%). Allergic asthmatic subjects had the greatest numbers of mast cells (1.86 Â± 0.48%); however, the numbers present in brushings from nonallergic asthmatic subjects were also increased (1.03 Â± 0.45%). The mast cells had the staining characteristics of mucosal mast cells, with formalin-blockable metachromatic staining and positive staining for tryptase. Both asthmatic groups also had elevated BAL eosinophils, and neutrophils were elevated in nonallergic asthmatic subjects. We conclude that bronchial brushings are a useful technique for sampling intraepithelial mast cells and that there is an accumulation of mast cells within the airway epithelium in asthma that is independent of allergy. The microenvironment within the bronchial epithelium may favor mast cell accumulation and the acquisition of a particular mast cell phenotype, which in turn may contribute to persisting airway inflammation and hyperresponsiveness in asthma.

Gibson PG, 'The overlap syndrome of asthma and COPD in older people: What are its features and how important is it?', Respirology (Abstracts of the 12th Congress of the Asian Pacific Society of Respirology), Gold Coast, Qld (2007) [E3]

Many patients with asthma use two or more drag classes. Poor inhalation technique limits drag efficacy. There has been an increase in the number and type of drug delivery systems ... [more]

Many patients with asthma use two or more drag classes. Poor inhalation technique limits drag efficacy. There has been an increase in the number and type of drug delivery systems available. This may accentuate the problems with poor inhalation technique and negate the advantage of drag delivery by inhalation. AIMS: The aims of this study are to describe the number of different devices used by patients with asthma, the adequacy of inhalation technique for each device and the effect of a structured education programme on technique and device selection. DESIGN: A cross sectional analytic survey. METHODS: Data was collected from patients attending the Asthma Management Service (AMS) between 1/1/00 and 30/9/00. Inhaler technique was assessed by an asthma educator and rated as adequate or inadequate. The number of devices used by each patient was analysed together with their proficiency of use. RESULTS: 123 patients were referred to the AMS and 112 (91%) attended an initial assessment. 54% were female and 25% were smokers. The age range was 17-79 years. 56% were on doses of ICS greater than 800mcgs/day. 74% of patients were using multiple devices. The patients were using an average of 1.9 different inhalation devices. Inadequate inhaler technique was present in 23% of pMDI users, 6% of spacer users, 29% of turbuhaler users, and 0% of Accuhaler users. Of those using multiple devices 26% were rated as inadequate with at least one of their devices. CONCLUSION: Inhaler polypharmacy exists as a unique problem among people with airways disease, and could lead to limited drag efficacy in a significant proportion of patients. There is a role for asthma education in the identification and management of this problem. :.

Severe and poorly controlled asthma may lead to adverse outcomes for mothers and their babies. An asthma management and education programme was established in the Antenatal Clinic... [more]

Severe and poorly controlled asthma may lead to adverse outcomes for mothers and their babies. An asthma management and education programme was established in the Antenatal Clinic (ANC) of John Hunter Hospital to optimise asthma management in pregnant women with asthma. Aim: The aim of this study was to evaluate the effect of the Asthma Management Service in the John Hunter Hospital ANC. Design: Longitudinal analytic survey. Method: Women were enrolled in their first trimester and underwent an initial assessment of asthma severity, treatment and management skills. Deficits were corrected by skills education, medical assessment and treatment. Records were reviewed of pregnant women with asthma who attended the Asthma Management Service between January 1998 and December 1999. Results: 83 women were enrolled and 72 patients attended between 2 and 8 visits during pregnancy, depending upon asthma severity. Conclusion: After structured asthma education, there were significant improvements in asthma knowledge and management skills. The antenatal clinic is a opportune setting for asthma education among pregnant women with asthma. Asthma Control Visit 1 After Education p Value Night Symptoms 53% 42% 0.15 Morning Symptoms 66% 46% 0.01 Activity Limitation 35% 30% 0.65 Asthma Skills pMDI: Inadequate 13% 0% 0.001 Spacer: Inadequate 2% 0% 0.50 Medication Knowledge 47% 88% 0.0001 Action Plan 13% 78% 0.0001 Peak Flow Monitoring 8% 78% 0.0001.

Jones PD, Henry RL, Francis L, Gibson PG, 'Chemotherapy reduces the prevalence of asthma symptoms in children with cancer: Implications for the role of airway inflammation in asthma', JOURNAL OF PAEDIATRICS AND CHILD HEALTH, CHRISTCHURCH, NEW ZEALAND (1999)

Investigation of the Immune Mechanisms in Pregnancy and Asthma Leading to Increased Susceptibility and Disease Severity to Respiratory Virus InfectionsGeneral Medicine, Faculty of Health and MedicinePrincipal Supervisor

2012

Exploring the Link Between Obesity and AsthmaGeneral Medicine, Faculty of Health and MedicineCo-Supervisor

2011

A Streptococcus pneumoniae-based Immunoregulatory Therapy for AsthmaMicrobiology, Faculty of Health and MedicineCo-Supervisor

2011

Asthma and COPD in Older PeopleGeneral Medicine, Faculty of Health and MedicinePrincipal Supervisor